Effect of tracheal gas insufflation during weaning from prolonged mechanical ventilation: a preliminary study.
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BACKGROUND: Tracheal gas insufflation reduces inspired tidal volume and minute ventilation in spontaneously breathing patients and may facilitate weaning from mechanical ventilation. OBJECTIVE: To determine if tracheal gas insufflation can reduce ventilatory demand during weaning trials in patients who require prolonged mechanical ventilation. METHODS: A reduction in ventilatory demand was defined as a relative decrease in tidal volume, minute ventilation, and mean inspiratory flow during trials with tracheal gas insufflation compared with the values during trials without this therapy. A total of 14 subjects underwent T-piece trials with and without insufflation (flow rate 6 L/min) on 2 consecutive days; the order of insufflation was randomized. Tidal volume, minute ventilation, and mean inspiratory flow were measured at baseline (without insufflation) and 2 hours later. RESULTS: Differences in ventilatory demand were not significant when comparisons were made for condition (tracheal gas insufflation vs no flow) or time (baseline vs 2 hours) for the total group (P = .48). Subjects were classified post hoc as responders (n = 9) or nonresponders (n = 5). Comparisons between responders and nonresponders indicated a significant (P = .02) 3-way multivariate interaction for group (responder vs nonresponder), condition (tracheal gas insufflation vs no flow), and time (baseline vs 2 hours) for ventilatory demand variables. CONCLUSION: Tracheal gas insufflation can reduce ventilatory demand during weaning trials in some patients who require mechanical ventilation. (+info)
Effects of a simple protocol on infective complications in intensive care unit patients undergoing percutaneous dilatational tracheostomy.
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In our intensive care unit we monitored infection in 228 patients who underwent percutaneous dilatational tracheostomy (PDT). In the first phase of the study 128 PDTs were performed during a 33-month period and there were 41 infection complications (nosocomial pneumonia, bacteremia with sepsis, and septic shock) in the perioperative period (immediately prior to and for 5 days after PDT). A significant risk factor among patients with nosocomial pneumonia was empirical administration of inappropriate antibiotics, compared to appropriate antibiotics (34% versus 4%, p < 0.001). In the second phase of the study (a 30-month period), a simple antibiotics protocol was prospectively applied to 100 PDT patients. The protocol virtually eliminated inappropriate antibiotic drug use immediately prior to PDT and contributed to a significant reduction in perioperative infective complications (pre-protocol 32% versus protocol 11%, p < 0.001). (+info)
Predictors of severe morbidity and death after elective abdominal aortic aneurysmectomy in patients with chronic obstructive pulmonary disease.
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OBJECTIVE: This study sought to identify risk factors associated with an unfavorable outcome after elective abdominal aortic aneurysm (AAA) repair in patients with chronic obstructive pulmonary disease (COPD). METHODS: The clinical records of 158 patients who underwent elective open AAA repair with COPD determined from preadmission International Classification of Diseases-ninth revision codes during a 12-year period at the University of Michigan were reviewed. Patients with uncomplicated outcomes (group I) were compared with those with unfavorable postoperative outcomes (group II). The unfavorable outcomes were defined as myocardial infarction, acute renal failure, worsening respiratory insufficiency necessitating tracheostomy, or death within 30 days of surgery. Logistic regression analyses of variables that were identified as being statistically significant in the univariate analysis were used to develop a predictive model of these events. RESULTS: Group I included 133 patients (77 men, 56 women) with a mean age of 70.1 years, and group II included 25 patients (13 men, 12 women) with a mean age of 71.4 years. Preoperative factors statistically related (P =.002) to an unfavorable outcome in group II patients included: suboptimal COPD management (fewer prescribed inhalers), lower hematocrit, preoperative renal insufficiency, and coronary artery disease. Importantly, abnormal preoperative spirometry and arterial blood gases were not predictive of a poor outcome. Univariate analysis also revealed increased hospital (25 versus 13 days; P =.0001) and intensive care unit (14 versus 4 days; P =.001) length of stays and a greater need for prolonged ventilation (8 versus 1 day; P =.039) for group II patients compared with group I patients. The 30-day mortality rate in the entire experience was 3.2% (5/158). No specific variables associated with mortality were identified. CONCLUSION: Fewer prescribed inhalers, lower hematocrit, renal insufficiency, and coronary artery disease are preoperative factors associated with unfavorable outcomes after open elective surgical repair of AAA in patients with COPD. Intensive management of these factors may reduce the hazards of AAA operations in these patients. COPD alone should not be considered a deterrent to the surgical treatment of AAAs. (+info)
How high do the subclavian arteries ascend into the neck? A population study using magnetic resonance imaging.
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BACKGROUND: The relationship between the larynx and the subclavian arteries was studied in a series of magnetic resonance images (MRIs) from 50 patients without neck pathology. METHODS: The vertical distances of the excursion of the subclavian arteries into the neck was measured, as was the distance from the cricoid cartilage to the highest point of this excursion. Statistical analysis allows the probability of any given cricoid-subclavian distance occurring in the population to be estimated. RESULTS: The mean (SD) excursion of the right subclavian artery above the clavicle was 10.4 (11.4) mm. The mean (SD) distance from the cricoid cartilage to the right subclavian artery was 30.6 (14.3) mm, and the data showed a high degree of variance. There was a linear relationship between neck length and cricoid-subclavian distance (r=0.58), which explained some of the variance in the latter, but there was also wide individual variance, which was independent of this regression. CONCLUSIONS: When performing a percutaneous tracheostomy, a 'safe' distance between the incision site and subclavian artery cannot be assumed or reliably predicted from the neck length. (+info)
Acute fatal haemorrhage during percutaneous dilatational tracheostomy.
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Percutaneous dilatational tracheostomy (PDT) is associated with a number of life-threatening complications. We present a case of massive and fatal arterial haemorrhage that occurred in the intensive care unit during an elective PDT on an 86-year-old woman following earlier evacuation of a traumatic subdural haematoma. An avulsed right subclavian artery was found at post mortem. Previous thyroid surgery and aberrant arterial anatomy contributed to the fatal outcome. (+info)
Tracheostomy following lung transplantation predictors and outcomes.
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The effect of tracheostomy on patients receiving lung transplantation is unknown. We reviewed our experience by performing a retrospective analysis on all lung transplant recipients at our institution. Patients were assigned to each study group based on whether or not they received a tracheostomy in the acute postoperative period. One hundred and fourteen lung transplants were performed, and 16 of those patients received a tracheostomy. In the tracheostomy group, more patients had undergone bilateral-lung transplantation (81% vs. 34%, p = 0.001), more required cardiopulmonary bypass (75% vs. 38%, p = 0.005), more acquired postoperative pneumonia (88% vs. 30%, p < 0.001), had greater reperfusion injury at 48 h (PaO2/FiO2 of 233 vs. 345, p = 0.047), had longer initial periods on the ventilator (21 +/- 7 vs. 2 +/- 0.5 days, p < 0.001), more required re-intubation (56% vs. 18%, p = 0.001), spent longer times in the intensive care unit (30 +/- 7 vs. 5.5 +/- 0.9 days, p < 0.001), and had longer lengths of stay (67 +/- 10 vs. 22 +/- 2 days, p < 0.001). Despite these differences between the two groups, a significant difference in survival at 180 days (75 vs. 81%) did not exist (p = 0.89). Although tracheostomy is more likely in sicker patients, it is not associated with poor long-term outcomes. (+info)
Bronchoscopic transillumination guidance for open standard surgical tracheostomy.
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The standard tracheostomy technique, described in 1909 by Jackson, has been increasingly used in intensive care units. Since 1957, several different types of percutaneous tracheostomy techniques have been described and performed with the support of bronchoscopic transillumination. The authors present the case of a respiratory failure due to obstruction of the upper airway by an exceptionally large goiter, which was successfully resolved by a standard open surgical tracheostomy. In this case, surgical tracheostomy was preceded by bronchoscopic transillumination, which facilitated identification of the appropriate tracheostomy site. (+info)
Lung volume effects on pharyngeal swallowing physiology.
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The experiment was a prospective, repeated-measures design intended to determine how the variation of lung volume affects specific measures of swallowing physiology. Swallows were recorded in 28 healthy subjects, who ranged in age from 21 to 40 yr (mean age of 29 yr), by using simultaneous videofluoroscopy, bipolar intramuscular electromyography, and respiratory inductance plethysmography. Each subject swallowed three standardized pudding-like consistency boluses at three randomized lung volumes: total lung capacity, functional residual capacity, and residual volume. The results showed that pharyngeal activity duration of deglutition for swallows produced at residual volume was significantly longer than those occurring at total lung capacity or at functional residual capacity. No significant differences were found for bolus transit time or intramuscular electromyography of the superior constrictor. The results of this experiment lend support to the hypothesis that the respiratory system may have a regulatory function related to swallowing and that positive subglottic air pressure may be important for swallowing integrity. Eventually, new treatment paradigms for oropharyngeal dysphagia that are based on respiratory physiology may be developed. (+info)